Retention of Nurse Managers Utilizing Skill Assessment and ...



Retention of Nurse Managers Utilizing Skill Assessment and Focused InterventionsKaren FugateUniversity of Central FloridaNGR 6723Carolyn HixApril 18, 2015Retention of Nurse Managers Utilizing Skill Assessment and Focused InterventionsBackgroundThe healthcare environment has become increasingly complex requiring a greater depth and breadth of knowledge including both clinical and operational oversight responsibilities for the nurse manager (NM) to be able to address and cope with rapid and relentless change (Oliver, Gallo, Griffin, White, & Fitzpatrick, 2014). Additionally, decreased reimbursement and increased hospital costs have resulted in all hospital leaders doing more with less (Zwink et al., 2013). At minimum, the NM is expected to meet organizational benchmarks in both quality and patient satisfaction requiring sophisticated administrative skills (Oliver et al., 2014; Zwink et al., 2013). Not only are NMs integral to organizational function, there are numerous studies correlating the impact of NMs to staff nurse satisfaction and retention (Oliver et al., 2014). The Institute of Medicine stated the decrease in number of NMs is one component of the work environment that has had a negative effect on nursing care quality and patient safety (Oliver et al., 2014). Decampli and Nash (2015) argue that administrators, regulatory agencies, medical staff members, and the community have come to count on the NM as the crucial leadership element leading to improved outcomes. Quint Studer, while recognizing the importance of front line staff to an organization’s success, emphasizes that managers engage them; therefore organizations need to place an increased focus on managers (Middaugh, 2014).Retention of nursing staff has become a priority in healthcare organizations and there are a number of studies identifying factors impacting staff nurse recruitment and retention. Less attention has been given to retention and recruitment of NMs (Zwink et al., 2013; Brown, Fraser, Wong, Muise, & Cummings, 2013). According to Oliver, et al. (2014), the Health Resources and Services Administration predicts a shortage of at least 67,000 clinical NMs by 2020 which is most likely a conservative estimate given the average age of the current NM is forty-nine. The cost of replacing NMs is estimated to be 75–125% of their annual salary, making a high turnover in this group a costly problem (Titzer, Phillips, Tooley, Hall, & Shirey, 2013). Exacerbating the problem, 82% of U.S. health care organizations report that recruiting qualified nurse managers is difficult (Titzer et al., 2013). Nurse managers often take months to attain competency, and during their role transition, productivity, nurse satisfaction and patient outcomes are adversely affected (Titzer et al., 2013). A recent study by Warshawsky and Havens (2014) found 70% of NMs intended to leave their position within five years; top reasons for leaving were burnout (30%), career change (27%), retirement (22%), and promotion (15%). Those expressing burnout as a reason to leave are not likely to present a favorable impression of the NM role to others with potential negative effects on recruitment. Additionally, organizations are experiencing a lack of interest in the NM position by younger staff (DeCampli & Nash, 2015). The void of NMs will have an increasingly negative effect on the ability of healthcare organizations to function optimally. As a result there is a growing impetus to seek ways to retain NMs as they are highly prized internal intellectual capital.ProblemLack of skill development and opportunity for professional growth is a common theme associated with NM dissatisfaction and intent to leave. According to Titzer et al. (2013), NMs are historically selected based on clinical skills and lack formal leadership preparation. Many organizations are not investing resources in the development of both current and future nurse leaders by helping them to build the skills needed to promote a healthy work environment (Sherman and Pross, 2010). To date, organizations rely on insufficient didactic education or on-the-job training resulting in ineffective leadership, turbulent role transition and high NM turnover rates (Titzer et al., 2013). Cziraki, McKey, Peachey, Baxter, and Flaherty (2014) describe “continuing to grow” as a retaining factor. Specifically, NMs cite the acquisition of new knowledge, skills, and expertise through education and leadership development programs, and leadership forums as organizational supports that allow for continued growth (Cziraki et al., 2014). In a systematic review of the literature, Brown et al. (2013) cite organizational culture and values as the most common organizational factor fundamental to the retention of NMs; two of the specific aspects described were lifelong learning and meaningful professional development. Oliver et al. (2014) report several lower than expected subscale scores on the Conditions of Work Effectiveness II Scale when surveying a large sample of NMs in fifteen hospitals. They attribute these scores to the changing role and increased responsibilities of NMs to include operational, quality, financial responsibility, as well as patient and staff satisfaction; NMs lack the necessary skills to address these responsibilities. One of the ways hospital leaders can help their managers as outlined by Middaugh (2014) and recommended by Quint Studer is to be generous and fair with professional development. According to Quint Studer, only about three out of ten people are natural leaders; all others require training to be successful (Middaugh, 2014). Role of the Nurse LeaderNurse leaders need to be cognizant of the critical impact competent nurse managers have on organizational success and just how difficult the position can be; from a CNO perspective, it might be one of the most difficult positions in the hospital (DeCampli & Nash, 2015). Understanding nurse manager concerns is fundamental to improving NM retention and satisfaction (Zwink et al., 2013). According to Oliver, et al. (2014), nurse executives should continually endeavor to develop NMs and raise them to higher levels. Leaders must identify where NMs are in their skill development and provide them with the necessary training to be successful (Middaugh, 2014). Nursing leadership is responsible for allocating resources directed at developing intellectual capital (Titzer et al., 2013) and ensuring nurse managers reach their full potential (Chace, 2015). One of the most significant contribution today's leaders can make for the future is to groom their successors so that they will adapt, thrive, and mature (Sherman & Pross, 2010). These emerging leaders will be responsible for continuing vital work to improve nursing work environments and most importantly patient outcomes (Sherman & Pross, 2010). The transformational nurse leader provides individualized consideration and intellectual stimulation to obtain higher levels of effort, motivation, and satisfaction from her followers (Huber, 2014); this is a particularly relevant senior nursing leadership quality as it relates to NM satisfaction and retention (Spence Laschinger, Wong, Grau, Read, & Pineau Stam, 2011).Possible SolutionsEmpirical evidence supporting succession planning and nurse manager retention as a sound health-care business strategy are limited (Brown et al., 2013; Titzer et al., 2013). The literature does make recommendations regarding considerations to develop NM skills including specific examples of program development. Although not an exhaustive list, the following describes such programs:DeCampli and Nash (2015) describe success with a professional coaching program tailored to the specific needs of the nurse manager discovered through interview with the manager and the manager’s peers, observations, and the manager’s completion of the American Organization of Nurse Executives’ (AONE) Nurse Manager Inventory Tool. Learning modules are then tailored for specific competencies. Sherman and Pross (2010) also suggest utilizing the Nurse Manager Inventory Tool to provide a useful structure to plan leadership development activities targeted to growing current and future nurse leaders. Oliver et al. (2014) suggest strategies to address structural empowerment including special courses or programs to assist the NM in developing strong leadership skills, generous tuition reimbursement to encourage professional development, NM meetings to provide a forum for support and strategy development, and collaborative care councils. Warshawsky & Havens (2014) recommend considering career development programs, mentoring, and strengthening leadership skills as possible solutions for NM retention. Zwink et al. (2013) describe a structured orientation and continued professional development curriculum specifically for NMs to strengthen NM competencies; at the time of publication, anecdotal reports of curriculum effectiveness were positive. Spence Laschinger et al. (2011) list increased access to resources, senior leadership support, professional development opportunities, educational and mentorship opportunities, and professional coaching as strategies to improve NM satisfaction and retention. Parry, Calarco, Hensinger, Kerly, and Shakarjian (2012) describe development of an on-line portal at the University of Michigan to enrich the role of the nurse manager, make supplemental development materials readily available, and increase efficiency in a fast-paced, increasingly complex environment. Waxman & Delucas (2014) describe simulation using competencies derived from AONE to hone soft leadership skills. Witges and Scanlan (2014) emphasize the need to incorporate the full-range leadership theory (FRLT) into organizational processes designed for leadership development.Chace (2015) describes three methods utilized at Indiana University Health Methodist Hospital to enhance leadership skills and potential two of which involve the use of external and internal programs. The external program involves support via the AONE Foundation Nurse Manager Fellowship which is a year-long program that only admits thirty fellows annually (Chace, 2015). The internal program involves use of the Methodist’s Nurse Manager Institute developed in 2012 which aims to assess competencies and focuses education based on competency assessment; the competency assessment is conducted via the Nurse Manager Inventory Tool.Selected SolutionAs described above, there are several strategies defined in the literature that seek to enhance NM skills and provide professional growth. Unfortunately, none of them provide specific measures of success. Several of the publications utilize the Nurse Manager Inventory Tool to evaluate competencies. The Nurse Manager Inventory Tool, developed by the Nurse Manager Leadership Partnership (NMLP) captures the skills and behaviors envisioned for the successful nurse manager (Nurse Manager Leadership Partnership [NMLP], 2006). The inventory allows the NM to perform a self-evaluation that is paired with the NM’s supervisor’s assessment to create an individualized professional development plan (NMLP, 2006). The inventory is based on three domains that the NM must master to be successful in today’s environment: 1) the “science” or managing the business, 2) the “leader within” or creating the leader in yourself, and 3) the “art” or leading the people (NMLP, 2006).It is challenging to predict what knowledge, skills, and abilities are needed to lead in the current and future healthcare system (Sherman & Pross, 2010). The large, complex skill set required for NMs to be successful combined with an overall dearth of resources in most healthcare settings would suggest it would be wise to choose a focused approach to the provision of skill-enhancing programs. It is neither efficient nor cost-effective to utilize resources to enhance all skills for all NMs; a much better approach would be to focus resources on identified weaknesses or opportunities for professional growth. My organization has extensive resources and expertise available to develop NMs; however there is no systematic process to evaluate opportunities for professional growth and to match NMs with identified opportunities to existing internal resources. Absence of planning for short-term results is one of the common pitfalls of strategic planning (Sare & Ogilvie, 2010); so although the ultimate goal is to increase NM retention, I have chosen to break down a very complex problem into realistic, manageable, and coherent components as suggested by Sare and Ogilvie (2010). I propose the following:Using the Nurse Manager Inventory Tool as a guide, outline internal resources available to develop skills in each of the content areas;Administer the Nurse Manager Inventory Tool to all NMs in the organization;Assign NMs with ratings of “novice experience/skill” to available internal resources to enhance specific skill setRe-administer the Nurse Manager Inventory Tool following completion of assigned internal resource enhancement program.Implementation PlanThe implementation plan is as follows:Selling the idea to senior nursing leadership – this is key for without senior nursing leadership buy-in the remaining steps are a moot point.Include NM vacancy rate, cost to replace NM, time it takes for new NM to be effective as described in the literatureInclude organization mean NM age, turn-over rate with prediction for future gap in NM roleInclude importance of NM competencies in driving staff nurse turn-over, patient satisfaction, quality of care, an overall organizational performanceDescribe competencies required of today’s NM to be successfulPoint out that organization does not currently have a systematic method to evaluate NM competencies or for NM to evaluate their own strengths and weaknessesDescribe the Nurse Manager Inventory Tool and suggestions for use as well documented use in the literatureProvide examples of how organization can meet skill gap with internal resourcesDescribe project Form project team of key stakeholders - Strategic planning requires that resources be realistically assessed (Sare & Ogilvie, 2010). Additionally, Sare and Olgivie (2010) warn that in the design stages of projects, perpetuation of “management by silos” leads to unrealistic strategic thinking and plans, complexity overload, and decision-making shortcuts. Therefore, it is imperative to involve key stakeholders in developing the plan. Stakeholders need to include those who can assist in determining internal resources for professional development: Human Resources, Organizational Development, at least one VP of Nursing Services, NMs (1 novice and 1 experienced), Finance, Nursing Quality, Nurse Research, Nurse Regulatory Compliance Officer, Business Intelligence, Nursing Informatics, Project Team Lead to move project along.Establish time line – risk loss of momentum and support from senior leadership if project does not progressIdentify internal resources available to address weaknesses in each of the content areas – pointless to administer inventory to NMs without a plan to address weaknesses.Determine best process to administer inventory - must include strategy to get “buy in” from NMs and their immediate supervisors. A fundamental principle of working with adults is that in order to effectively engage them in any process, they must appreciate the meaning as it is relevant to them (Sare & Ogilvie, 2010).Determine process for NM supervisors to assign NM to resourcesWho to contactTime frame for completionClose the loop – did NM complete agreed upon enhancement activity?Determine process to collect and analyze inventory responses and specifics of enhancement activities – essential metrics for baseline measures and post implementation measures of successPlan EvaluationProcess and outcome measures are needed for any quality improvement project. Process measures describe how the system works and outcome measures are used to determine if the change in process made a difference. Measures should be specific, measurable, agreed upon, realistic, and time-based or SMART (Haughey, 2015). The table below details measures I would suggest to evaluate the success of this project.MeasureProcessOutcome1.NMs completing inventory (% of total calculated as # of NM completing inventory ÷ total # of NMs in organization)X2.NM direct supervisors meeting with NM to reconcile inventory (% of total calculated as # of NM direct supervisors meeting with NM to reconcile inventory ÷ total # of NM completing inventory)X3.Referrals to specific professional development activities or resources (# of referrals to each identified activity)X4.Change in mean scores on inventory sections pre and post project (calculate mean by total scores of all NMs on sections using a 4 point Likert scale ÷ total number of NMs completing section; calculate baseline (pre) and post projectXThis would be a project worth sharing since there is only anecdotal mention in the literature of successful programs aimed at enhancing the skill sets of NMs. Studies or quality improvement projects with quantitative data are needed to inform practice. Untapped potential in a NM is a terrible thing to waste particularly if it contributes to NM dissatisfaction and turn-over. ReferencesBrown, P., Fraser, K., Wong, C. A., Muise, M., & Cummings, G. (2013). Factors influencing intentions to stay and retention of nurse managers: A systematic review. Journal of Nursing Management, 21, 459-472. , L. K. (2015). The nurse manager whisperer: Chief Nursing Officer methods to develop nurse managers. Voice of Nursing Leadership, 12(2), 12-14.Cziraki, K., McKey, C., Peachey, G., Baxter, P., & Flaherty, B. (2014). Factors that facilitate Registered Nurses in their first-line nurse manager role. Journal of Nursing Management, 22, 1005-1014. , P., & Nash, J. (2015). Leadership coaching: Smarter than Cliff Notes. Nurse Leader, 13(1), 27-29. , D. (2015). SMART goals. Retrieved from , D. L. (2014). Leadership and management prinicples. In D. L. Huber (Ed.), Leadership & nursing care management (5th ed. (pp. 1-36). St. Louis, MO: Elsevier-Saunders.Middaugh, D. J. (2014). Monkey in the middle! MedSurg Nursing, 23(3), 192-193.Nurse Manager Leadership Partnership. (2006). Nurse manager skills inventory. Retrieved from , B., Gallo, K., Griffin, M. Q., White, M., & Fitzpatrick, J. (2014). Structural empowerment of clinical nurse managers. JONA, 44(4), 226-231.Parry, J., Calarco, M. M., Hensinger, B., Kerly, G., & Shakarjian, L. (2012). An online portal to support the role of the nurse manager. Nursing Economic$, 30(4), 230-232.Sare, M. V., & Ogilvie, L. (2010). Strategic planning for nurses: Change management in healthcare. Retrieved from , R., & Pross, E. (2010). Growing future nurse leaders to build and sustain healthy work environments at the unit level. Online Journal of Issues in Nursing, 15(1), 4.Spence Laschinger, H. K., Wong, C. A., Grau, A. L., Read, E. A., & Pineau Stam, L. M. (2011). The influence of leadership practices and empowerment on Canadian nurse manager outcomes. Journal of Nursing Management, 20, 877-888. , J., Phillips, T., Tooley, S., Hall, N., & Shirey, M. (2013). Nurse manager succession planning: Synthesis of the evidence. Journal of Nursing Management, 21(7), 971-979. , N. E., & Havens, D. S. (2014). Nurse manager job satisfaction and intent to leave. Nursing Economic$, 32(1), 32-39.Waxman, K., & Delucas, C. (2014). Succession planning: Using simulation to develop nurse leaders for the future. Nurse Leader, 12(5), 24-28. , K. A., & Scanlan, J. M. (2014). Understanding the role of the nurse manager: The full-range leadership theory perspective. Nurse Leader, 12(6), 67-70.Zwink, J. E., Dzialo, M., Fink, R. M., Oman, K. S., Shiskowsky, K., Waite, K., ... Le-Lazar, J. T. (2013). Nurse manager perceptions of role satisfaction and retention at an academic medical center. JONA, 43(3), 135-141. ................
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